Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification
Abstract
Background
Different pharmacological approaches aimed at opioid detoxification are effective. Nevertheless a majority of patients relapse to heroin use, and relapses are a substantial problem in the rehabilitation of heroin users. Some studies have suggested that the sorts of symptoms which are most distressing to addicts during detoxification are psychological rather than physiological symptoms associated with the withdrawal syndrome.
Objectives
To evaluate the effectiveness of any psychosocial plus any pharmacological interventions versus any pharmacological alone for opioid detoxification, in helping patients to complete the treatment, reduce the use of substances and improve health and social status.
Search methods
We searched the Cochrane Drugs and Alcohol Group trials register (14 April 2003). Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2003), MEDLINE (January 1966 to April 2003); EMBASE (January 1980 to April 2003); PsycINFO (1985 to April 2003) and reference list of articles.
Selection criteria
Randomised controlled trials which focus on any psychosocial associated with any pharmacological intervention aimed at opioid detoxification. People less than 18 years of age and pregnant women were excluded.
Data collection and analysis
Three reviewers independently assessed trials quality and extracted data.
Main results
Eight studies involving 423 people were included. These studies considered five different psychosocial interventions and two substitution detoxification treatments: Methadone and Buprenorphine. The results show promising benefit from adding any psychosocial treatment to any substitution detoxification treatment in terms of completion of treatment relative risk (RR) 1.68 (95% confidence interval (CI) 1.11 to 2.55), results at follow‐up RR 2.43 (95% CI 1.61 to 3.66), and compliance RR 0.48 (95% CI 0.38 to 0.59). With regard to the use of heroin during treatment, the differences were not statistically significant but favoured the combined treatments.
Authors' conclusions
Psychosocial treatments offered in addition to pharmacological detoxification treatments are effective in terms of completion of treatment, results at follow‐up and compliance. Although a treatment, like detoxification, that exclusively attenuates the severity of opiate withdrawal symptoms can be at best partially effective for a chronic relapsing disorder like opiate dependence, this type of treatment is an essential step prior to longer‐term drug‐free treatment and it is desirable to develop adjunct psychosocial approaches that might make detoxification more effective. Limitations to this review are imposed by the heterogeneity of the assessment of outcomes. Because of lack of detailed information no meta analysis could be performed to analyse the results related to several outcomes.
PICOs
Plain language summary
People who abuse opioid drugs and become dependent on them experience social issues and health risks. Medications such as methadone and buprenorphine are substituted to help dependent drug users detoxify and return to living drug free, by reducing physiological withdrawal symptoms (pharmacological detoxification). Yet psychological symptoms can occur during detoxification and may be distressing. It is often a personal crisis that led to a drug user deciding to detoxify. Furthermore the psychological reasons why a person became addicted are important. They may not be able to cope with stress and have come to expect that using mood modifying illicit substances helps. Even after successful return to a drug‐free state, many people return to heroin use and re‐addiction is a substantial problem in rehabilitation. The physiological, behavioural and social conditions in an individual's life that made them an opiate addict may still be present when physical dependence on the drug has been eliminated, which makes psychosocial therapy important. Psychosocial treatments include behavioural treatments, counselling and family therapy.
The review authors searched the medical literature and found evidence that providing a psychosocial treatment in addition to pharmacological detoxification treatment to adults who are dependent on heroin use is effective in facilitating opioid detoxification. This conclusion is based on eight controlled studies involving 423 adults, about three‐quarters men, with an average age of 31 years (28 to 41 years). The studies lasted 16 days to 26 weeks. The addition of a psychosocial treatment to substitution detoxification treatment improved the number of people who completed treatment (relative risk (RR) 1.7), abstinence from drugs at follow up (RR 2.4), and halved the number of failures to attend clinic absences. The findings of an improved rate of clinical attendance may help in suppressing illicit drug use and provides clinical staff with more opportunities to counsel patients in psychiatric, employment and other drug and non‐drug related areas. Variations in the populations who are substance users and use of a wide range of different psychosocial interventions means that it is difficult to single out particular therapeutic interventions.
